by Nick Edwards
I examined him, and X-rayed his hand. His finger was broken, but the facial bones were normal. Now I don’t really know why, but he didn’t like this fact. I think he must have wanted them broken so he could press charges or something, and so when I tried for the fifth time to explain that he hadn’t fractured his face, he called into question my masturbatory practices and implied that I f**k in a quite incestuous way (for the record I have quite an average masturbatory practice and have a very conventional sex life).
I had seen this bloke in the past and remembered that he was usually pleasant but this time because of booze, he had got himself beaten up and then become obnoxious. The time was only 10.45 p.m., so he had also ruined a potentially good night out. That was the second example of cautionless use of alcohol.
After grabbing a coffee, I saw my next patient. Some university students had been on a drinking binge all day, gone to a party and one of the girls had become so pissed she couldn’t talk.
‘She has had her drink spiked, she must have,’ her friends informed me.
‘So what has she drunk then?’ I asked.
‘Five double JDs and coke, five VOs and seven bottles of WKD.’
After deciphering the letters into drinks and then into units, I soon realised that I would be pissed on half of what she had drunk.
‘She can normally handle her drink and so she must have had it spiked. Can’t you do a test to prove it?’
I explained that this amount of booze will make you completely unconscious and that it is not usual to test for ‘spiked drinks’. Her drink was already spiked with JD (Jack Daniels), VO (vodka and orange) and whatever alcohol they put into bottles of ‘Wicked’ (WKD).
The girl’s night was ruined–she was so paralytic she wasn’t bothered about the puke in her hair and didn’t seem to care that she had wet herself. Our nurses’ time was taken up by cleaning her up and my time was taken up by putting up a drip and giving her some fluids to help wake her up. Until she was safe and we were confident that she wouldn’t choke on her own vomit, we had to keep her on a precious bed on the A&E ward with constant supervision. Because she so overindulged, our taxes paid for her to be cared for and she got a shit night. When she left in the morning, we didn’t even get a thank you.
It makes you think that if booze wasn’t so relatively cheap (especially alcopops and especially at university bars/drinks promotions nights), then she might not have the money to spend on this much booze, especially with tuition fees and the cost of shoes, etc. Maybe the government should think about increasing the price of booze, especially alcopops, as a deterrent to this sort of behaviour. I’ll leave that to them and continue my recollections of last night.
While I was writing my patient notes, the ‘red phone’ went off. Ambulance control informed us that there had been a serious incident. A cyclist had been hit by a car doing 50 m.p.h. The cyclist was seriously injured.
I called the trauma team and the cavalry arrived–albeit a slightly bleary-eyed cavalry, moaning that they had been woken up and saying, ‘I bet it is a load of bollocks–I want to go back to bed.’ I arranged the team and got ready to lead them. The patient arrived a minute or two later.
It wasn’t a load of bollocks at all. The ambulance men had done a brilliant job in getting the patient here so quickly as well as starting vital fluid resuscitation. But he was in a bad way. His heart rate was high and blood pressure low and his abdomen was rigid. (Coincidentally, my heart rate was off the scale, BP sky high and rectal continence indeterminate). He needed an emergency operation–no time for a CT scan. He needed his abdomen opening and the source of bleeding found and stopped. While explaining all this to him, all I could do was notice the stench of alcohol from his breath. This man was as pissed as a fart. No wonder he hadn’t needed much analgesia. He was rushed to theatre and a bleeding spleen was found that had to be removed. He will now need lifelong antibiotics, a week or two in ICU and weeks of intensive rehabilitation…oh, and a new bike.
The drink–drive message is starting to get through to people, but we seem to forget that it is also dangerous to drink and cycle. The majority of pedestrians injured in the evening have also been drinking and this may have contributed to their injury. Please remember this when you are running across the road after six pints–the green cross code still applies even if the kebab shop is about to close.
During the time it takes to run a trauma call, a lot of senior doctors and nurses are tied up and the other patients in the department end up having to wait a long time. The next patient had been waiting over 5 hours to be seen (3 hours 59 minutes in management timing). He was 16 and had gone over to his mate’s house as he had a ‘free house’. (Not a pub, but his parents had gone out for the evening.) He came in with his friend’s parents after they found him vomiting (in their sock drawer for some bizarre reason) and because he couldn’t walk straight or speak in a coherent manner.
They had initially tried to go to the pub, but first couldn’t get served and second couldn’t afford a pint anywhere except at the local Wetherspoon’s and his granddad was there so he didn’t particularly want to go in. They decided to go to the local supermarket with the friend’s 19-year-old brother. Now I can hardly complain that he tried his best to obtain alcohol underage. I used to try every trick in the book–even resorting to brewing our own alcoholic drink in the local woods (you don’t need to be 18 to buy yeast). But when I drank underage, I couldn’t afford as much as this young lad could with his paper-round money. At the supermarket they managed to buy two packs of 20 bottles of Stella for something ridiculous like £14.99–reassuringly dirt cheap, unlike the adverts would have us believe. These supermarkets are deliberately using amazing offers, potentially as loss leaders, to encourage people into their shops. This is ridiculous and just encourages excessive alcohol consumption.
The drinks industry doesn’t approve either, because it is encouraging a form of drinking much worse than in a pub–isolated and without social interaction…or high profit margins. In the process the price war is causing local pubs to close. Can the government not stop this practice? I want more sensible red tape to protect the public. Why can’t these supermarkets go back to their original loss leaders and sell baked beans for a penny, instead of shed loads of booze for not much?
Anyway, the young lad was examined and left to sleep it off till he was safe to go home. His parents then came in and I started to feel a little sorry for him–he got such a bollocking it was unbelievable, but also quite amusing.
So far it was five out of five patients who had been to A&E because of booze. The next patient I saw was an overdose. Yippee! Not an alcohol-related patient…except I had jumped to the wrong conclusion. He had taken a bottle of vitamin pills after drinking a bottle of JD (a very popular drink, I am finding out). The pills won’t cause him any harm, but he needed a psychiatrist because he really did want to die and he thought the tablets would kill him. However, because he was pissed, no psychiatrist would see him until he had sobered up. He was someone else who was parked on a valuable observation bed for the night.
Six out of six became eight out of eight. Accompanied by the local constabulary two fine young members of the public had been brought in with various cuts and bruises. They had been to a local pub and got into a fight; police were called and then they were brought to us to get them checked out and stitched. Just so that the police wouldn’t have to hang around for hours, I saw them promptly–no major injuries–just bruises. It was a waste of my time and it meant other more needy patients were not seen so speedily.
The pub in question is notorious–a new one built where I used to pay in cheques. They have also got a late licence–allowed by the government which is trying to encourage a continental café-style drinking culture and not a ‘drink up, roll your sleeves up and fight’ culture. However, at this new pub, they still have lots of heavy drinking and no one goes for a ‘quiet coffee’. Why not? Well, the pub chains care about profit and not social responsibility and
so to maximise profits they built a ‘vertical drinking bar’ as opposed to a French-style café. What this means is that you cannot sit down to have your drink slowly, the music is loud so you can’t chat and there are no tables to rest your drink. So all you can do is drink till you get paralytic. If the councils just thought a little harder and granted late licences only to pubs that actually encouraged a café-style drinking culture (i.e. by having seats) then it might help with our booze problem. It is not a genius idea, just common sense.
Nine out of nine was a twisted ankle while running for a taxi, pissed, number 10 was a head injury after falling over, pissed, and numbers 11 and 12 were another fight (over who was looking at whose bird), pissed and pissed.
Reading this, you may think that I have a Presbyterian view of the new drinking laws–I don’t. The 24-hour laws have, in my opinion, and that of a recent government report, not increased or decreased alcohol-related problems coming to us but just spread the workload over from what was originally 11 p.m.–1 a.m. to 11 p.m.–5 a.m.
The new rules have also done a lot of good. Police and local councils can liaise with the A&E departments about local problem pubs and they have been warned to buck up their ideas or lose their licences. The A&E consultants can also advise police and councils on safety issues. After consultation with one A&E department in Wales, a decision was made to force one pub/club to only sell booze in plastic bottles/glasses. The incidence of serious injuries decreased massively.
After an interval of three non-alcohol related patients I got my 13th booze-related patient: a Latvian builder whom I can only assume had misread the bottle label after work and drunk vodka instead of water (these mistakes do happen). He came in to ask if I could give him something to stop him vomiting and feeling so dizzy as he had to go and fix someone’s roof soon! At least it won’t be me who sees him when he comes back–it’s my last shift for a few days and I am off to the pub now for a fry-up and a pint (the best bit about the new licensing laws).
Upset at work
One case really upset me today. An old lady came in struggling to breathe. She was about 85. We tried all we could but soon her breathing stopped, as did her heart. We started CPR. Occasionally it works, but it was obvious in this case it wasn’t going to work either: 15 minutes later, I checked with the team if anybody minded if we stopped. Nobody did. I went to speak to her husband.
‘Is she dead?’ he asked without emotion.
I nodded. ‘Oh…what do I do now? I haven’t been on my own for 64 years. May I see her?’
I tried to explain what had happened but he just wanted to see his wife.
He looked at her. ‘I love you’, he said, with tears rolling down his face he added. ‘See you in Heaven,’ and then he left.
It really upset me. However long you have done this job you do get upset. Also, you know that he will be back soon, as invariably widowed men die shortly after their spouses. I tried to get a cup of tea when the red phone went off and another patient came in–a chance for reflection was stopped by a multiple trauma.
My last thoughts
Today was my last day at work before a two-week holiday and the break from writing that would ensue. The main thing writing this book has done for me is actually to get me to think about what I do as opposed to just go through the motions.
As I drove home to the sounds of REM (who always put me in contemplative mood), I started to think about my job and day. Yes, I had had a good day. I had seen lots of varied and interesting cases (medical term for patients/people), ranging from a heart attack to a broken finger. I had seen a patient whose condition had really made me upset, but also made me thankful for what I have got. I had an email from a medical student thanking me for a teaching session I gave a couple of weeks ago, and positive feedback from my boss about a patient I had treated. I had flirted with the nurses, and patients over 80, and had had a good bit of banter with my colleagues.
So, all in all, it wasn’t so bad a day. To top it off, we hadn’t been worried about 4-hour waiting targets as we seemed to be well-staffed today. So, on a good day, I think there is no other job in the world that I would prefer.
On a bad day, well, that is different. The stresses of dealing with such heart-breaking cases can be hard to cope with. The nervousness about making a mistake and the worry that your treatment will do no good, are hard to live with. There is the paranoia of getting a complaint from a patient. Then there is the anxiety of a getting a bad reputation from your bosses for not managing the department efficiently or being thought of as shit by your specialist colleagues for not sorting out patients in the manner they deem appropriate. Combine all that with the worry of exams, revalidation and working your way up the career ladder when you now have no idea of what is waiting for you at the top, then it leads to a difficult job. However, I think the good bits outweigh the bad bits.
So, I think to myself, do I want to carry on? Well, yes I do. Hopefully, in a few years I’ll be a consultant and, although that means more responsibility and extra challenges, it also means that I will have a voice and perhaps some power in trying to direct changes in an appropriate way as opposed to just being swept along with them.
Would I recommend being an A&E doctor to school kids, medical students and my own child? Yes…but only if they are mentally strong and can cope with the stress and upset involved in the job, only if they don’t take criticism to heart, only if they have ‘bouncebackability’ (thank you for that word, Iain Dowie) and only if they can rationalize what is important in life and not get so stressed by problems of complaints, difficulties with management, and the uncertainty of their chosen career. If you are like me and possess none of these qualities, would I still recommend A&E as a career? Yes, as long as you have the love, support and compassion of a partner to help you through it all and support you when it gets rough. Luckily, I have the best possible one: Mrs Edwards, everything I do, you make do-able and worthwhile. Thank you.
Apologies, acknowledgments, thank yous
and hopes
It is unusual to start this type of ending with an apologies section. However, I think that it is probably wise. Very rarely have I mentioned the many colleagues (including many managers) who work very hard to help A&E departments function well and help provide good quality of care for patients. This is not because they are rare–far from it–they are the rule, it is just the exceptions that really drive me mad and make me write to vent anger. If a biased view has come across, then I apologise.
I have many thank yous to say. First, to the publishers for agreeing to sign a contract without seeing much of my work and just based on me ranting while having a tired cup of coffee after a set of nights. Second, to my agent for leading me through a process that I know so little about. I would also like to thank my friends for being supportive and listening to my rants down the pub.
I would like to thank all the staff I work with and the thousands of others who keep the NHS going. My particular thanks go to my recent immediate bosses for helping train me and showing how to keep your head when everyone else is moaning and ranting.
I would like to thank my family: my parents for their moral compass, my brother for his advice and my in-laws for encouraging me to write this book and giving me the idea in the first place. Most importantly, I would like to thank my wife. You have given me so much, including our precious child. This book has only been possible because of your support. Thank you. I love you so much. You have an unlimited shoe and handbag budget this year, I promise.
So that just takes us on to hopes and conclusions. I hope that you have enjoyed the book, and that it has opened your eyes to the reality of the subject material. I have shown you why I love my job and why it also drives me crazy. Generally, I think that things have got better in the NHS and emergency medicine in the last 10 years. The money pumped in has seen improvements. I think that the government’s intentions have been right; it’s just their actions that have been at fault. The problems have been the unintended consequen
ce of poorly thought-out policies.
The NHS is an institution that I care about deeply. Policies have been brought in that tamper with its principles and ethos. I fear that the structural changes that have been brought in may lead to a patchwork privatisation and a consequential degradation in service provision. I hope a post-Blair era proves me wrong. If you too are worried, then try and do something to help save the NHS. We live in a democracy and our voices should count. Go on marches against your local hospital closure, sign petitions, write to your MP or get involved with pressure groups (such as http://www.keepournhspublic.com). If you have any comments or wish to contact me please do so via The Friday Project or at [email protected].
Thank you.
Dr Nick Edwards, July 2007
Epilogue
Four years on and so much has changed. For me, personally, I have nearly completed my registrar training, including spending 18 months working as an intensive care doctor, to improve my skills with the sickest of patients in the resuscitation room. I have recently passed my fellowship exams and am now ready to apply for a consultant job. Sixteen years after starting medical school it will be great to stop being a junior doctor.